Synthesis: what have we learned?

We marked our tenth anniversary in October 2014 and published a synthesis of the learning to date and the implications for policy and practice. Our own evidence base, in line with a substantial body of international research, demonstrates that economic, environmental and social factors all influence the health of individuals and communities.

The ten year synthesis outlined a set of interlinked issues – poverty, early life experience, neighbourhood environments and social contexts – are at the heart of inequality and consequently health inequality in Glasgow. Services, interventions and approaches to improve outcomes are woven through these issues and have their own effect. The wide-ranging actions required to improve life expectancy and reduce health inequalities were outlined in the ten year synthesis report and accompanying summary leaflet.

The key learning from the ten year synthesis was that actions need to be taken across all the areas outlined in the diagram in an integrated and sustained way. Nevertheless, it can be helpful to drill down into the evidence about particular areas to maximise learning and provide clarity about the areas for action.

Overall, our evidence base and a large body of international health evidence, emphasises the critical importance of addressing poverty. Poverty is the most ubiquitous and persistent risk factor for ill health; so a commitment to improving population health and to reducing health inequalities inherently means a commitment to reducing or eradicating poverty.

Social contexts

During discussions about the ten year synthesis with our partner organisations and networks it emerged that there was an interest in increasing understanding about the links between people’s health and their social contexts, and the related actions that can be taken to improve health.

Our review of social contexts evidence outlines the health impacts and key actions relating to people’s relationships and networks of support, interconnections within communities, and the involvement of people and communities in decisions that affect their lives.

Excess mortality

Much of the poor health of Scotland, and its largest city, Glasgow, are explained by experiences of deindustrialisation, deprivation and poverty. However, in addition, high levels of 'excess'mortality – that is, higher mortality over and above that explained by differences in socioeconomic deprivation – have been observed for Scotland compared with England & Wales, as well as for Glasgow compared with similar post-industrial UK cities.

Alongside NHS Health Scotland and other partners, we have undertaken a considerable amount of research into this excess, and a report published in May 2016 identified the most likely causes. In Glasgow’s case these related to a complex set of multiple, interwoven, factors. Key to these was the fact that the city’s population was made more vulnerable to important socioeconomic (poverty, deprivation, deindustrialisation) and political (detrimental economic policies) exposures, resulting in more adverse outcomes compared with other cities like Liverpool and Manchester.

This vulnerability was generated by a series of historical factors/processes including: the lagged effects of high, historical, levels of overcrowding; Scottish Office policy in post-war decades including the socially-selective relocation of population to outside the city; more detrimental processes of urban change resulting in relatively worse living conditions; and differences in local government responses to UK economic policy in the 1980s which conferred protective effects on comparator cities. Further resulting protective factors were identified e.g. greater social capital in Liverpool. A number of other contributory factors were highlighted, including the inadequate measurement of living in deprived circumstances in the city.

Download the full report, which includes a detailed set of policy recommendations aimed at national and local government, and the findings of which were endorsed by a range of experts in public health and other relevant disciplines.

This synthesis draws on ten plus years of outputs and events from the GCPH and GoWell to outline compelling evidence about the importance of early years’ and childhood experiences for healthy development and for health and wellbeing throughout the life course. The report outlines evidence about the different ‘spheres’ of influence impacting on children’s health and wellbeing:

Family and parent environment – Fundamental to healthy child development and attachment is the family/household environment, the health and wellbeing of the child’s parents (or main carers) and crucially, consistent love and care.

Learning environment – Early years settings and schools exert critical influences on children’s development and future outcomes.

Neighbourhood environment – The neighbourhoods in which children and young people live and socialise have significant impacts on their day-to-day lives and their health and wellbeing.

Socioeconomic context – The health and wellbeing of children is directly influenced by material circumstances. Socioeconomic factors interact with and impact across children’s family, learning and neighbourhood environments.

Interacting with all of these, and having their own effect, are the services, interventions and approaches undertaken to improve outcomes for individuals and communities. This review increases understanding of how the whole of society, as well as effective universal services and targeted interventions, can support and nurture all children during this critical life stage. A number of consistent and important themes emerge from the evidence:

Emotional attachment - Strong bonds and positive relationships within families, in schools and in neighbourhoods are crucial to children’s healthy development and underpin their future development of good relationships and good parenting.

Safety - Not feeling safe at home can have damaging long-lasting impacts for children into adulthood; levels of safety and cohesion in schools impact on health and wellbeing; and use and enjoyment of neighbourhoods is affected by experiences and perceptions of safety.

Healing approaches - A lack of attachment and stressful experiences impact negatively on physical and emotional development, with potentially life-long consequences. However, there is also significant capacity for healing through changing circumstances, nurturing approaches, and supporting resilience through family support, schools, communities and services.

Understanding different circumstances - There is a need for approaches and service delivery to understand and respond to differences in personal circumstances. In particular, to prevent and mitigate against the impacts of poverty and inequalities.

Involvement in decision-making - Children and young people need to be involved in decisions affecting their lives within their family environments, schools and neighbourhoods. Meaningful involvement is required which influences outcomes.

Active travel

In 2007, we established a programme of work to gather and analyse information about levels of active travel, to improve understanding of trends and influences on travel choices, and to evaluate the impact of transport policies and programmes on active, sustainable travel in Glasgow and the Clyde Valley area.

Since then the programme has collated and analysed national survey and routine data to provide information and trends on modes of travel and casualties for different population groups, conducted wide-ranging research to explore travel patterns and attitudes towards active travel in and around Glasgow, and convened seminars and workshops to discuss the emerging issues and possible ways forward.

The report emphasises the importance of:

greater leadership and investment in active travel, and improved co-ordination across transport, planning, health improvement, air quality and climate change policies and programmes

raising the profile of active travel in urban planning and infrastructure development

supporting culture and behaviour change, as part of a wider strategic approach

improving monitoring data on active travel, in order to understand which interventions are impacting on active travel trends and how.